moderate“mental capacity assessments did not detail what people could and could not do, and for some people there was no clarification on whether they could consent to care”
moderate“We asked the registered manager for details of Lasting Power of Attorney (LPA)... however there were no court records in people's files.”
moderate“best interest meetings had not always taken place when necessary... We found least restrictive options for care had not been recorded.”
governance
3 findings
moderate“We found audits did not always identify issues... when issues were identified they were not always followed up.”
minor
“people said they had never seen the collated results of surveys or questionnaires”
minor“We looked at a selection of policies and procedures. We found some were not up-to-date and did not reflect best practice.”
medication management
1 finding
moderate“two people's creams had been applied more frequently than recommended and topical products were not always dated when opened”
care planning
1 finding
moderate“we found one person had no risk assessment for choking despite carers telling us they struggled to eat some foods”
missed or late visits
1 finding
moderate“Staffing levels were sufficient to meet people's needs, however sometimes staff were late to attend calls.”
staffing levels
1 finding
moderate“we saw staff rotas were produced with no, or little, travel time between calls and we saw errors were sometimes made on the rotas requiring staff to be at two calls at the same time”
record keeping
1 finding
minor“some records required updating to reflect people's recent change in needs”